anaemia in chronic kidney disease (CKD)

Last edited 09/2021 and last reviewed 07/2022

• management of anaemia: with anaemia of chronic kidney disease (CKD) (1)
  • consider investigating and managing anaemia in people with CKD if:
    • their Hb level falls to 11 g/dl or less (or 10.5 g/dl or less if younger than 2 years) or
    • they develop symptoms attributable to anaemia (such as tiredness, shortness of breath, lethargy and palpitations
  • diagnostic role of glomerular fifiltration rate
    • in adults, children and young people with anaemia (see below re: diagnostic tests to determine iron status and predict response to iron therapy)
      • if eGFR is above 60 ml/min/1.73 m2, investigate other causes of anaemia as it is unlikely to be caused by CKD
      • if eGFR is between 30 and 60 ml/min/1.73 m2:
        • investigate other causes of anaemia, but
        • use clinical judgement to decide how extensive this investigation should be, because the anaemia may be caused by CKD
      • if eGFR is below 30 ml/min/1.73 m2, think about other causes of anaemia but note that anaemia is often caused by CKD
      
      
• the correction to normal levels of Hb with erythropoiesis-stimulating agents (ESAs) is not usually recommended in people with anaemia of CKD:
  • typically maintain the aspirational Hb range between 100 and 120 g/l for adults, young people and children aged 2 years and older, and between 95 and 115 g/l for children younger than 2 years of age, reflecting the lower normal range in that age group
  • to keep the Hb level within the aspirational range, do not wait until Hb levels are outside the aspirational range before adjusting treatment (for example, take action when Hb levels are within 0.5 g/dl of the range's limits)
    
    
• diagnostic tests to determine iron status and predict response to iron therapy
  • carry out testing to diagnose iron deficiency and determine potential responsiveness to iron therapy and long-term iron requirements every 3 months (every 1-3 months for people receiving haemodialysis)
    
    
    • use percentage of hypochromic red blood cells (% HRC; more than 6%), but only if processing of blood sample is possible within 6 hours
      
      
    • if using percentage of hypochromic red blood cells is not possible, use reticulocyte haemoglobin (Hb) content (CHr; less than 29 pg) or equivalent tests - for example, reticulocyte Hb equivalent
      
      
    • if these tests are not available or the person has thalassaemia or thalassaemia trait, use a combination of transferrin saturation (less than 20%) and serum ferritin measurement (less than 100micrograms/litre)
      
      
  • do not request transferrin saturation or serum ferritin measurement alone to assess iron deficiency status in people with anaemia of chronic kidney disease (CKD)
    
    
• treatment with erythropoiesis-stimulating agents (ESAs) should be offered to people with anaemia of CKD who are likely to benefit in terms of quality of life and physical function
  
  
• ESAs: monitoring iron status during treatment
  • offer iron therapy to people receiving ESA maintenance therapy to keep their:
    
    
    • percentage of hypochromic red blood cells less than 6% (unless serum ferritin is greater than 800 micrograms/litre)
      
      
    • reticulocyte Hb count or equivalent tests above 29 pg (unless serum ferritin is greater than 800 micrograms/litre)
      
      
    • transferrin saturation level above 20% and serum ferritin level above 100 micrograms/ litre (unless serum ferritin is greater than 800 micrograms/litre)
      
      
  • the marker of iron status should be monitored every 1-3 months in people receiving haemodialysis
    
    
  • in people who are pre-dialysis or receiving peritoneal dialysis, levels are typically monitored every 3 months. If these people have a normal full blood count there is little benefit in checking iron status

Notes:

• aspirational range and action thresholds for Hb

  • When determining individual aspirational Hb ranges for people with anaemia of CKD, take into account:
    • patient preferences
    • symptoms and comorbidities
    • the required treatment

Reference:

• 1)NICE (August 2021). Chronic kidney disease: assessment and management